Provider Demographics
NPI:1821051160
Name:PETROFSKY, STEPHEN (DPM)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:PETROFSKY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 HARBOR BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33952-5342
Mailing Address - Country:US
Mailing Address - Phone:941-625-3330
Mailing Address - Fax:941-625-5753
Practice Address - Street 1:2525 HARBOR BLVD
Practice Address - Street 2:SUITE 206
Practice Address - City:PT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5342
Practice Address - Country:US
Practice Address - Phone:941-625-3330
Practice Address - Fax:941-625-5753
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO000791213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT55419Medicare UPIN
FL1313650001Medicare NSC
FL87324Medicare ID - Type Unspecified